LTC Bullet:  The LTC Problem and Solutions:  Thousand Bullets Retrospective

Friday, February 8, 2013


LTC Comment:  Overview 15 years of the “LTC Problem and Solutions” after the ***news.***

*** TODAY'S LTC BULLET is sponsored by Claude Thau, a General Agent whose proprietary sales tools enable clients to make informed final decisions about buying LTCi in 15-20 minutes, let you evaluate a client's real interest in a combo product in a few minutes, and change work-site LTCi from a proposal-delivery process to interactive consultation. Claude is the lead author of the Milliman Broker World LTCi Survey, was named one of the 10 "Power People" in the LTCi industry by Senior Market Advisor in 2007 and was Chairman of the Board of the Center for Long-Term Care Financing. Test Claude by calling 800-999-3026, x2241 or email him at to ask questions or get references. ***

*** LTC COMMISSION UPDATE.  Appointments to the “Commission on Long-Term Care” created by the “American Taxpayer Relief Act of 2012” are not exactly off to a propitious start.  So far, six people have been named to the Commission and all six advocate government-dominated LTC financing.  One appointee, Judith Stein, Director of the Center for Medicare Advocacy, is actually a former president of the National Academy of Elder Law Attorneys, the Medicaid estate planners’ trade association!  The rest of the people appointed so far are listed here.  Still to make their appointments to the Commission are the President (D), the Minority Leader of the Senate (R) and the Speaker of the House (R).  Let’s hope someone ends up on the LTC Commission who understands and can explain how government-based LTC financing has hurt long-term care and how market-based solutions are the only way to improve it. ***

*** VOICE OF REASON.  As the following LTC Bullet documents, your Center for LTC Reform has for nearly 15 years explained “how government-based LTC financing has hurt long-term care and how market-based solutions are the only way to improve it.”  The LTC Commission needs to hear our message and we intend to deliver it proudly, frankly, and often.  Help us by getting involved.  Join the Center or upgrade your membership.  All our membership levels and benefits are described here.  Once the LTC Commission is appointed and staffed, we’ll be conveying our message to it in many different ways.  We’ll write letters, op-eds, and articles.  You can help by working with us to regale Commission members and the politicians and academics who influence them with hard evidence, solid reasoning, and irrefutable recommendations.  To join the Center or upgrade your membership, contact Damon at 206-283-7036 or ***



LTC Comment:  Once a week, usually on Fridays, we publish our LTC Bullet.  The Bullets are often policy pieces, sort of like op-eds.  You can always find the five latest Bullets here and archives of all 988 Bullets (so far), by date here and by topic here.  These nearly-1000 articles are a valuable historical resource.  Please make use of them.  Search for key terms using Control-F on your keyboard.

This year, in celebration of the thousandth LTC Bullet (likely to be issued some time in April) and the Center’s 15th anniversary (April 1), we are releasing a retrospective of the most interesting and dramatic LTC Bullets that we’ve published since the Center’s founding in 1998.  We’ll highlight one Bullet per year in each of seven major topics:  “The LTC Problem and Solutions”; “Reality Check:  The Facts on LTCI”; “Medicaid Planning”; “LTC Services”; “Politics and Legislation”; “Demographics and Other Data”; and “CLTCR News.” 

Today’s Bullet is our “Thousand Bullets Retrospective” Number 1 covering “The LTC Problem and Solutions.”  Read our summary and check out the original at the link provided.  Enjoy this walk down memory lane.


September 8, 1998 LTC Bullet:  An Open Letter to the Medicare Commission.  Appointing commissions is the government’s way of dodging and postponing problems.  The new LTC Commission is unlikely to be an exception.  Certainly “The National Bipartisan Commission on the Future of Medicare,” created by Congress in the Balanced Budget Act of 1997, solved nothing.  In this LTC Bullet, released by the then-only-five-months-old Center for Long-Term Care Financing, Steve Moses addressed the Medicare Commission in an open letter later published by LTC News & Comment:  “Wouldn't it be a big load off the Commission's back if the long-term care problem really could be solved easily and inexpensively?  Here's the answer in a nutshell:  America's long-term care difficulties are largely self-inflicted.  We have been trying to solve the wrong problem.  Our costly attempts to improve long-term care over the years have ironically made the situation worse.  Why?”  He proceeded to explain the problem and the solution in this Bullet.

September 1, 1999 Study Shows Most Can Afford LTC Insurance.  “‘Most Americans can afford private long-term care insurance and would buy it if well-intentioned government programs didn't anesthetize the public to this huge financial risk.’  With that statement, Stephen A. Moses, President of The Center for Long-Term Care Financing in Seattle, WA released a white paper today entitled ‘The Myth of Unaffordability:  How Most Americans Should, Could and Would Buy Private Long-Term Care Insurance.’  According to Moses, ‘this report explains why only 7% of seniors and virtually none of the critical baby-boomer generation have purchased private long-term care insurance.  It shows that 70% to 80% of Americans could afford this coverage if they felt the need to buy it.  The report explains how easy access to government-financed long-term care services has impeded the market for private insurance, assisted living and home care.  Finally, 'The Myth of Unaffordability' offers a workable, cost-free, public policy solution--called LTC Choice--that would improve access to quality long-term care for rich and poor alike.’”  Read this Bullet and “The Myth of Unaffordability.”

December 7, 2000 LTC Bullet: LTC: What's Wrong, Who's to Blame, How to Fix.  "America's long-term care service delivery and financing system is a tragic mess. The symptoms include widespread bankruptcies, collapsed stocks, scant capital, scarce staffing, high costs, low government reimbursement, little private insurance, declining quality, expanding litigation, skyrocketing liability premiums, persistent institutional bias, and a growing generation of overwhelmed family caregivers. Unfortunately, aging demographics signal that the worst is yet to come. What's wrong? Who's responsible? What should be done? Those are the questions this study set out to address."  With that statement, Stephen A. Moses, President of The Center for Long-Term Care Financing in Bellevue, Washington released a report today entitled The LTC Triathlon: Long-Term Care's Race for Survival. Based on telephone interviews with 119 of the leading private financiers, providers and insurers of long-term care, The LTC Triathlon study is a penetrating analysis and critique of long-term care public policy.  Read this Bullet and “The LTC Triathlon.”

May 11, 2001 LTC Bullet: How to Avoid the Long-Term Care Trap.  "LTC Bullets readers often ask us for sample speeches from which they can draw ideas to use in their own public addresses. We've obliged occasionally by posting transcripts of lectures delivered by Center for LTC Financing President Steve Moses on our website at We've received so much positive feedback on these postings that we have decided to add more of Steve's talks to the site.  The speech we are posting today is entitled 'How to Avoid the Long-Term Care Trap.' You can find the transcript at  Steve delivered this talk on March 10, 2001 to a consumer audience at 'Money Watch Live 2001' in New Orleans. This annual financial planning mega-conference attracts 6,000 to 7,000 people and is well known as the premier event of its kind in the U.S.”  Read this Bullet and “How to Avoid the Long-Term Care Trap.”

October 24, 2002 LTC Bullet--How To Save Medicaid LTC.  “The following article by Claude Thau, President of Thau, Inc. and Chairman of the Board of Directors of the Center for Long-Term Care Financing, describes a key aspect of the Center's LTC Choice proposal:  Through Medicaid, we do two wonderful things for people who need long-term care (LTC). First, we all pay taxes so that indigent people can get commercial LTC that they otherwise would not be able to afford. We should all feel proud to contribute to that cause. Secondly, we provide support to people who are NOT indigent. If people were to sell their homes in order to pay for LTC, and then were to recover, they would no longer have a home to return to. To avoid such an undesirable result, we give loans to these people, advancing their LTC costs, with the intention of recovering when their estate is settled [through Medicaid estate recovery]. Not only do we pool our money to provide a loan to such people, we provide that loan on an interest-free basis! It is a long-term loan as it does not require repayment until the care recipient dies. And, if the recipient's spouse is living in the house, the loan does not have to be repaid until (s)he dies. If disabled or minor children live in the house or if adult children who were care-givers for a couple of years live in the house, the loan continues until they die or sell the house. It is wonderful that we provide such loans, but such loans should be provided OUTSIDE the Medicaid program.” Read this Bullet and the rest of Claude’s classic article.

March 12, 2003 LTC Bullet: The Elephant, The Blind Men and Long-Term Care. This article by Stephen A. Moses would be good advice to the newly appointed members of the latest “LTC Commission.” “Three blind men approached an elephant. One touched the elephant's trunk and exclaimed, ‘a hose.’ The second grabbed the elephant's leg and said, ‘a telephone pole.’ The third reached for the elephant's tail and concluded, ‘a rope.’ The allegory of the blind men and the elephant teaches us the folly of making conclusions about any complex thing without comprehending its entirety. What can we learn about long-term care from this ancient parable? Long-term care is a complex subject comprised of many inter-related parts. When people, even experts, analyze one facet of long-term care without taking into consideration all of its aspects and inter-relationships, they often reach wrong, incomplete or misleading conclusions. Who are the ‘blind men’ of long-term care? What mistaken suppositions do they tend to make? And what can we learn if we remove our blindfolds and observe long-term care in its fullness and complexity?”  Read this Bullet or a version published in National Underwriter of “The Elephant, The Blind Men, and Long-Term Care.”

September 7, 2004 LTC Bullet: The Realist's Guide to Medicaid and Long-Term Care.  “The Center for Long-Term Care Financing, a [then] nonprofit think tank and public policy organization, released a new report today titled ‘The Realist's Guide to Medicaid and Long-Term Care.’ The report explains (1) how America's long-term care service delivery and financing system became plagued by quality problems and bankruptcies, (2) why Medicaid, a welfare program, dominates long-term care funding and causes institutional bias, and (3) what must be changed in public policy to control explosive Medicaid costs and improve access to quality long-term care for everyone.  ‘The Realist's Guide to Medicaid and Long-Term Care’ also highlights ten states, five of the worst and five of the best for long-term care policy.”  Read this Bullet and “The Realist’s Guide to Medicaid and Long-Term Care.”  Book review:

"Steve Moses and the Center for Long-Term Care Financing have established the knowledge base and foundation from which the future of LTC and eldercare is emerging. As I have examined and learned from their work over the years, I have found that their views have always been insightful, bold, astute, and 'early!' I encourage everyone in the field of aging to review the Center's new report 'The Realist's Guide to Medicaid and Long-Term Care.'"

Ken Dychtwald, Ph.D.
President of Age Wave,
Author of Age Wave, Age Power and Healthy Aging

September 1, 2005 LTC Bullet: Aging America's Achilles' Heel.  “Following is the Cato Institute's press release announcing publication of a new ‘policy analysis’ titled Aging America's Achilles' Heel: Medicaid Long-Term Care. ‘Medicaid Long-Term Care Abuse Is Rampant. Study urges Congress to eliminate loopholes for long-term care recipients.  WASHINGTON -- Medicaid is a fiscal crisis waiting to happen, warns a study released today by the Cato Institute. In Aging America's Achilles' Heel: Medicaid Long-Term Care, Stephen Moses, president of the Center for Long-Term-Care Reform, exposes how Medicaid is exploited to finance nursing home care for many seniors who could have financed such care themselves.  Moses explains that while Medicaid's financial eligibility rules are relatively tight for poor women and children, ‘for people over the age of 65 who have medical need for nursing-home-level care, Medicaid's eligibility rules -- contrary to conventional wisdom -- are very loose.’”  Read this Bullet and Aging America's Achilles' Heel: Medicaid Long-Term Care.

November 16, 2006 LTC Bullet: The Brave New World of Long-Term Care.  "The Brave New World of Long-Term Care" presented by Stephen A. Moses to the Notre Dame Law School Symposium on Aging, Notre Dame, IN: Thank you for inviting me to Notre Dame Law School. It is an honor to address you and to share the podium with such distinguished co-presenters.  . . .  I chose ‘The Brave New World of Long-Term Care’ as my topic today. But let me start by describing the ‘Pusillanimous Old World of Long-Term Care,’ that is, the status quo.”  Read this Bullet and “The Brave New World of Long-Term Care.”   

March 16, 2007 LTC Bullet: Don't Mess With Texans' LTC--Fix It!.  "Don't Tread on Texans' Long-Term Care-Fix It! By Stephen A. Moses.  If the nation isn’t prepared for the aging baby boomers, it isn’t because the boomers sneaked up on us. For some time, we have seen the warnings and been conscious of the coming ‘age wave.’ The problem is that few have taken heed and been moved to act thus far. While national leaders warn about the coming collapse of Medicare and Social Security, state lawmakers grow increasingly concerned about meeting the increasing demand and cost of Medicaid long-term care as the boomers age. To stave off the coming disaster, state lawmakers need to respond quickly to embrace every ounce of the limited federal flexibility available. Read this Bullet and “Don’t Mess With Texans’ LTC—Fix it!.”

February 7, 2008 LTC Bullet: Hillary on LTC.  “Hillary Clinton on LTC by Stephen Moses:  Presidential candidate Senator Hillary Clinton has promised a cornucopia of LTC benefits if elected. Would our service delivery and financing system be better or worse if she delivered? Hillary Clinton announced her plans for long-term care public policy a few weeks ago. Let's give due credit: none of the other presidential candidates have committed themselves to anything like such a detailed plan. At least she's on the record, with lots of ideas, some of which are very appealing. First a synopsis, then our comments . . ..”  Read this Bullet and “Hillary Clinton on LTC.”

April 15, 2009 LTC Bullet: Do We Need an LTC Tea Party?.  “Across the country today, at 300 locations in all 50 states, citizens are staging ‘tea parties’ to protest high taxes and explosive public spending. That got me thinking: Do We Need an LTC Tea Party? Think about it. We have a new President, a new administration, a new focus on fixing government, on helping those in need, and on holding those in power accountable. So why not tackle the utter inequities in our long-term care financing system? For example, Medicaid is the dominant funder of long-term care. It's supposedly a safety net for the poor. But in truth it pays for most expensive LTC for nearly everyone, thus crowding out privately financed home care and LTC insurance to pay for it. What's fair about that?”  Read this Bullet.

January 15, 2010 LTC Bullet: "Doing LTC RIght" or The Medicaid Mouse that Roared.  “The State of Rhode Island took a daring leap into radical Medicaid reform last year. The state requested and the Centers for Medicare and Medicaid Services (CMS) granted a ‘global Medicaid waiver.’ Under this unique plan, Rhode Island agreed to a cap on Medicaid matching funds for five years in exchange for more flexibility to administer the program than federal law and regulations otherwise allow. Among other objectives, the state is using the global waiver to increase Medicaid-financed home and community-based services while reducing nursing home utilization. Rhode Island's gutsy move and noble goals are praiseworthy. But will they save money or break the bank? Will offering more services people want (home care) and fewer they'd rather avoid (nursing homes) swell Medicaid ranks? How will home care providers fare with higher acuity patients? How will nursing homes survive with fewer low-acuity (profitable) residents? Why are low-acuity patients in expensive skilled nursing facilities in the first place? Can private financing alternatives like insurance and reverse mortgages grow if Medicaid LTC becomes more attractive than ever? Is Rhode Island jumping from the fiscal frying pan into a financial firestorm? What might the state do with its global Medicaid waiver authority to reinvent and save the LTC safety net? Can Rhode Island get it right and become a model for the rest of the country? Our new report, titled ‘Doing LTC RIght,’ released today in collaboration with the Providence-based Ocean State Policy Research Institute, answers all these questions.”  Read this Bullet or “Doing LTC RIght.” 

January 5, 2011 LTC Bullet: "Medi-Cal LTC: Safety Net or Hammock?" Report Released “Today, the Pacific Research Institute released our report on Medicaid and long-term care financing in California titled ‘Medi-Cal Long-Term Care: Safety Net or Hammock?’ PRI's press release follows below. Find links to the full study and a longer version of the press release here: The report is also posted on the Center's website here  Now, check out the ‘movie’ PRI prepared spoofing Medi-Cal's egregious LTC eligibility loopholes as documented in the report: - p/a/u/0/eyOpCWIJYC4. We at the Center for Long-Term Care Reform wish to thank the Pacific Research Institute and its staff for their thoughtful and creative work to bring this report to publication and to promote it with ingenuity and humor.”  Read this Bullet and “Medi-Cal Long-Term Care: Safety Net or Hammock.”

February 3, 2012 LTC Bullet: How to Fix Long-Term Care.  The Center for Long-Term Care Reform’s late summer, early fall  [2011] project in Washington, DC produced seven important deliverables. As described in our project report titled “Near-Term Prospects for Long-Term Care Financing Reform,” these work products included:

1. "Pay for the Doc Fix by Fixing Medicaid LTC"
2.Save Medicaid LTC $30 Billion Per Year AND Improve the Program"
3. & 4. Letters from members or committees of Congress to both the GAO and the DHHS Inspector General requesting studies relevant to our project's objectives.
5. "
Medicaid Long-Term Care Benefits: Friendly Fire in the Class War": Steve Moses’s testimony published by Congress.
6. "Challenges to Effective Long-Term Care: Cost and Affordability": Steve Moses’s speech to the 13th annual Health Sector Assembly in Sundance, UT.
7. Six “Briefing Papers” on “How to Fix Long-Term Care” with an “Overview” linking to each.

Today’s LTC Bullet conveys our “Overview” of “How to Fix Long-Term Care.” Subsequent LTC Bullets will deliver each of our six Briefing Papers in serial form. We hope that by reading this material you will gain a better understanding of why America’s long-term care delivery and financing system is so dysfunctional and what it will take to fix the problem. Thanks for supporting the Center for Long-Term Care Reform.

Read this Bullet and “How to Fix LTC.”